How to manage diverticulitis (inflammation of the diverticula) without antibiotics?

From the Guidelines

Managing mild diverticulitis without antibiotics involves focusing on a clear liquid diet, pain management, and hydration, as antibiotics are not necessary for uncomplicated cases, according to the most recent guidelines. The American College of Physicians suggests that clinicians initially manage select patients with acute uncomplicated left-sided colonic diverticulitis without antibiotics 1. This approach is supported by recent studies that have shown no significant difference in outcomes between patients treated with and without antibiotics for uncomplicated diverticulitis 1.

Key Components of Management

• Diet: A clear liquid diet is recommended for 2-3 days during flare-ups, followed by a gradual transition to a low-fiber diet and eventually a high-fiber diet (25-30g daily) once symptoms improve 1.
• Pain Management: Acetaminophen (Tylenol) 500-1000mg every 6 hours as needed for pain, avoiding NSAIDs like ibuprofen which can irritate the digestive tract.
• Hydration: Stay well-hydrated with at least 8-10 glasses of water daily.
• Symptom Management: Apply a heating pad to the abdomen for 15-20 minutes several times daily to reduce discomfort.

Prevention of Future Episodes

• Maintain a high-fiber diet with fruits, vegetables, and whole grains.
• Exercise regularly for 30 minutes most days.
• Manage stress through techniques like deep breathing or meditation.

When to Seek Medical Attention

• Severe pain.
• Persistent fever above 100.4°F.
• Inability to keep liquids down.
• Blood in stool, as these may indicate complications requiring antibiotics or other medical interventions.

From the Research

Diverticulitis Management Without Antibiotics

• Diverticulitis is a common complication of diverticular disease of the colon, and its management has become more conservative over the years 2, 3.
• Studies have shown that acute uncomplicated diverticulitis (AUD) can be managed without antibiotics, with treatment failure rates ranging from 4-5.1% 2, 4.
• A systematic review and meta-analysis found no significant differences between non-antibiotic and antibiotic treatment groups regarding rates of treatment failure, recurrence of diverticulitis, complications, readmission rates, need for surgery, and mortality 2.
• Another study found that the rate of emergency surgery within 30 days may be lower with no antibiotics compared to antibiotics, but the evidence is uncertain due to wide confidence intervals 5.
• Patient subgroups, such as those with immunosuppression or non-steroidal anti-inflammatory drugs, may have a higher risk of complicated diverticulitis, but young patients do not seem to have a higher risk of recurrent diverticulitis 3.

Treatment Strategies

• Conservative treatment strategies for AUD include:
  • No antibiotics 2, 4
  • No bed rest 3
  • No dietary restrictions 3
  • Outpatient treatment for selected patients 3
• Fiber-rich diet and fiber supplementation may help reduce intraluminal pressure and slow down the worsening of the disease 6.
• Rifaximin and probiotics have been studied insufficiently in acute diverticulitis patients to conclude on their efficacy 3.

Complications and Recurrence

• Complications, such as fistulas, abscesses, and perforations, are more common in patients with complicated diverticulitis 4, 6.
• Recurrence rates for AUD range from 5-11% 2, 4.
• Elective surgery may be necessary for some patients, especially those with recurrent diverticulitis or complicated disease 4, 6.